Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis

The impact of the COVID-19 pandemic on acute appendicitis patients in a tertiary care center in Lebanon

INTRODUCTION

With it becoming a global pandemic, the coronavirus disease of 2019 (COVID-19) imposed public health restraints that hampered patient's presentation to hospitals. In Lebanon, little is known about the presentation patterns of acute appendicitis (AA) patients among different population groups during the COVID-19. Therefore, this study aims to assess the effects of the COVID-19 pandemic on the rates of cases seen during the pandemic period, the adopted management strategies, and evaluate the patient outcomes compared to presentations from previous years.

METHODS

This is a retrospective, observational cohort study with no interventional procedures. All patients presented to our tertiary health care center were diagnosed with AA between February 2019 and February 2021 comprised the study analysis. We divided our patients into the pre-pandemic period cohort March 1st, 2019, till February 29th, 2020, and the pandemic period cohort March 1st 2020 till March 1st 2021.

RESULTS

We collected data retrospectively from 342 patients: 201 patients presented in the pre-pandemic period and 141 during the pandemic period. Male predominance was seen in both cohorts (51.7% and 58.9% respectively). A decrease in the number of AA cases was seen during the pandemic, however, the duration of symptoms before presentation was similar in both cohorts (p = 0.382) Additionally, the number of complicated appendicitis cases was not different between cohorts. The main imaging modality was CT in both groups with no statistically significant difference in the type of imaging between them (p = 0.398). Further, the predominant treatment modality remained surgery during the pandemic, with no difference between both periods (p = 0.200), and no statistically significant difference in the type of surgery performed as laparoscopic surgery remained the most common surgery type in the pandemic period (p = 0.43). Finally, no extra surgical and post-surgical complications were identified.

CONCLUSION

In conclusion, our study is an example of how the COVID-19 pandemic did not significantly affect patients presenting for AA. Despite the COVID-19-related restrictions, Lebanese patients with worrying symptoms were presenting to the emergency department and the American University of Beirut Medical Center was providing them with the standards of care. Our study mirrors the Lebanese experience and gives an example of a population that focused more on their current symptoms than the fear of acquiring the COVID-19 virus. Further research is needed to assess whether this was the correct approach during these times.

Management and outcomes of acute appendicitis in children during the COVID-19 pandemic: a systematic review and meta-analysis

The COVID-19 pandemic has changed the way to manage the emergencies, as people faced fear of the hospitals, with possible delay in the diagnosis. Moreover, clinicians had to rearrange protocols for diagnosis and treatment. We aimed to assess whether COVID-19 pandemic influenced severity of inflammation, management, and outcomes of acute appendicitis (AA), when compared to the pre-COVID era. Using defined search strategy, two independent investigators identified those studies comparing pediatric AA during COVID-19 pandemic versus the pre-COVID-19 period. Meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 528 abstracts, 36 comparative studies were included (32,704pts). Time from symptoms onset to surgery was longer during the pandemics compared to the pre-COVID-19 (1.6 ± 0.9 versus 1.4 ± 0.9 days; p < 0.00001). Minimally Invasive Surgery was similar during COVID-19 (70.4 ± 30.2%) versus control period (69.6 ± 25.3%; p = ns). Complicated appendicitis was increased during the pandemics (35.9 ± 14.8%) compared to control period (33.4 ± 17.2%; p < 0.0001). Post-operative complications were comparable between these two groups (7.7 ± 6.5% versus 9.1 ± 5.3%; p = ns). It seems that the COVID-19 pandemic influenced the time of diagnosis, severity of inflammation, and type of surgery. However, the number of post-operative complications was not different between the two groups, leading to the conclusion that the patients were correctly managed. LEVEL OF EVIDENCE: Level 3 Meta-analysis on Level 3 studies.

Moving to Medical Treatment for COVID-19 Influence on Pediatric Appendicitis: A Meta-Analysis

Acute appendicitis (AA) is cited as the leading cause of surgical acute abdomen in pediatrics and the most frequent urgent surgical pathology worldwide. For a long time, surgical appendectomy has been effectively used as the first-line treatment for AA. Other conservative management practices, such as the use of antibiotics, have been applied in the treatment of appendicitis. COVID-19 has had a significant impact on the surgical treatment strategies of AA in pediatrics, with many pediatric surgeons having to shift from upfront surgical appendectomy to conservative management involving the use of antibiotics as a treatment strategy. This meta-analysis compares the outcomes between appendectomy and conservative therapy in the management of AA during COVID-19 in pediatrics. Twenty-one articles fully met the inclusion criteria. Articles that were published more than five years ago were excluded from the analysis. Also, articles that included studies on the adult population were excluded. Results from various retrospective studies, prospective clinical controlled trials, correlational studies, and randomized clinical trials were analyzed. This study reveals that the use of antibiotics has been demonstrated to be safe and effective in the treatment of uncomplicated appendicitis. However, antibiotics have been shown to have some complications. Despite this being the case, the studies identified the potential of using antibiotics as a definitive treatment of uncomplicated AA in pediatrics. Further studies are required to evaluate the cost-effectiveness and recurrence of AA of this alternative treatment method.

Hospital length of stay for COVID-19 patients: A systematic review and meta-analysis

The length of stay in the hospital for COVID-19 can aid in understanding the disease's prognosis. Thus, the goal of this study was to collectively estimate the hospital length of stay (LoS) in COVID-19 hospitalized individuals. To locate related studies, international databases (including Google Scholar, Science Direct, PubMed, and Scopus) were searched. The I² index, the Cochran Q test, and T² were used to analyze study heterogeneity. The mean LoS in COVID- 19 hospitalized patients was estimated using a random-effects model. COVID-19's total pooled estimated hospital LoS was 15.35, 95%CI:13.47-17.23; p<0.001, I² = 80.0). South America had the highest pooled estimated hospital LoS of COVID-19 among the continents, at 20.85 (95%CI: 14.80-26.91; p<0.001, I² = 0.01), whereas Africa had the lowest at 8.56 8 (95%CI: 1.00-22.76). The >60 age group had the highest pooled estimated COVID-19 hospital LoS of 16.60 (95%CI: 12.94-20.25; p<0.001, I² = 82.6), while the 40 age group had the lowest hospital LoS of 10.15 (95% CI: 4.90-15.39, p<0.001, I² = 22.1). The metanalysis revealed that COVID-19's hospital LoS was more than 10 days. However, it appears that this duration varies depending on a number of factors, including the patient's age and the availability of resources.

Testicular torsion during the COVID-19 pandemic: Results of a multicenter study in northern Italy

INTRODUCTION

The literature reported an increased avoidance of the Emergency Department (ED) during COrona VIrus Disease 19 (COVID-19) pandemic, causing a subsequent increase of morbidity and mortality for acute conditions. Testicular torsion is a surgical emergency, which can lead to the loss of the affected testicle if a delayed treatment occurs. As testicular loss is time-related, outcome was hypothesized to be negatively affected by the pandemic.

OBJECTIVE

The aim is to investigate whether presentation, treatment and outcomes of children with testicular torsion were delayed during COVID-19.

STUDY DESIGN

Medical records of pediatric patients operated for testicular torsion of six Paediatric Surgical Units in Northern Italy between January 2019 and December 2020 were retrospectively reviewed. Patients were divided as for ones treated during (dC) or before the pandemic (pC). To reflect possible seasonality, related to lockdown restrictions, winter and summer calendar blocks were also analysed. For all cohorts, demographic data, pre-operative evaluation, operative notes and post-operative outcomes were reviewed. Primary outcomes were referral time, time from diagnosis to surgery and ischemic time, while secondary outcomes were orchiectomy and atrophy rates. Statistic was conducted as appropriate.

RESULTS

A total of 188 patients with acute testicular torsion were included in the study period, 89 in the pre-COVID-19 (pC) period and 99 during COVID-19 (dC). Time from symptom onset to the access to the Emergency Department (T1) was not different among the two populations (pC: 5,5 h, dC: 6 h, p 0.374), and similarly time from diagnosis to surgery (pC: 2,5 h, dC: 2,5 h, p 0.970) and ischemic time (pC: 8,2 h, dC: 10 h, p 0.655). T1 was <6 h in 46/99 patients (46%) pC and 45/89 patients (51%) dC (p = 0.88, Fisher's exact test). Subgroup analysis accounting for different lockdown measures, confirm the absence of any difference. Orchiectomies rate was 23% (23/99) dC and 21% (19/89) pC (p = 0.861, Fisher's exact test) and rate of post-operative atrophy was 9% dC (7/76) and 14% pC (10/70), p = 0,44, Fisher's exact test.

DISCUSSION

Despite worldwide pediatric ED accesses reduction, we reported that neither ischemic time nor the long-term outcomes in children with testicular torsion increased during the COVID-19 pandemic. In the available literature, few studies investigated the topic and are controversial on the results. Similarly to our findings, some studies found that timing and orchiectomy rates were not significantly different during the pandemic, while others reported a correlation to pandemic seasonality. Furthermore, in the recent pediatric literature it has been reported a delayed testicular torsion diagnosis due to shame in informing parents. Strengths of this study are the large numerosity, its multicentric design and a long study period. Its main limitation is being retrospective.

CONCLUSIONS

We reported our large cohort from one of the most heavily COVID-19-affected regions, finding that referral, intra-hospital protocols and ischemic time in testicular torsion were not increased during to the pandemic, as well as orchiectomy rate and atrophy.

Clinical Experience of Emergency Appendectomy under the COVID-19 Pandemic in a Single Institution in South Korea

Background and Objectives: The COVID-19 pandemic has brought serious changes in healthcare systems worldwide, some of which have affected patients who need emergency surgery. Acute appendicitis is the most common surgical disease requiring emergency surgery. This study was performed to determine how the COVID-19 pandemic has changed the treatment of patients with acute appendicitis in South Korea. Materials and Methods: We retrospectively reviewed a medical database that included patients who underwent surgery for acute appendicitis in our hospital from January 2019 to May 2021. We classified the patients into two groups according to whether they were treated before or after the COVID pandemic and 10 March 2020 was used as the cutoff date, which is when the World Health Organization declared the COVID pandemic. Results: A total of 444 patients were included in the “Pre-COVID-19” group and 393 patients were included in the “COVID-19” group. In the “COVID-19” group, the proportion of patients with severe morbidity was significantly lower. The time that the patients spent in the emergency room before surgery was significantly longer in the ”COVID-19” group (519.11 ± 486.57 min vs. 705.27 ± 512.59 min; p-value < 0.001). There was no difference observed in the severity of appendicitis or in the extent of surgery between the two groups. Conclusions: During the COVID-19 pandemic, a statistically significant time delay (186.16 min) was needed to confirm COVID-19 infection status. However, there was no clinical difference in the severity of appendicitis or in the extent of surgery. To ensure the safety of patients and medical staff, a COVID-19 PCR test should be performed.

Consequences of Social Distancing Measures During the COVID-19 Pandemic First Wave on the Epidemiology of Children Admitted to Pediatric Emergency Departments and Pediatric Intensive Care Units: A Systematic Review

Objectives

To synthesize knowledge describing the impact of social distancing measures (SDM) during the first wave of the COVID-19 pandemic on acute illness in children by focusing on the admission to pediatric emergency departments (PED) and pediatric intensive care units (PICU).

Methods

We searched Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, EPOC Register, MEDLINE, Evidence-Based Medicine Reviews, EMBASE, WHO database on COVID-19, Cochrane Resources on COVID-19, Oxford COVID-19 Evidence Service, Google Scholar for literature on COVID-19 including pre-print engines such as medRxiv, bioRxiv, Litcovid and SSRN for unpublished studies on COVID-19 in December 2020. We did not apply study design filtering. The primary outcomes of interest were the global incidence of admission to PICU and PED, disease etiologies, and elective/emergency surgeries, compared to the historical cohort in each studied region, country, or hospital.

Results

We identified 6,660 records and eighty-seven articles met our inclusion criteria. All the studies were with before and after study design compared with the historical data, with an overall high risk of bias. The median daily PED admissions decreased to 65% in 39 included studies and a 54% reduction in PICU admission in eight studies. A significant decline was reported in acute respiratory illness and LRTI in five studies with a median decrease of 63%. We did not find a consistent trend in the incidence of poisoning, but there was an increasing trend in burns, DKA, and a downward trend in trauma and unplanned surgeries.

Conclusions

SDMs in the first wave of the COVID-19 pandemic reduced the global incidence of pediatric acute illnesses. However, some disease groups, such as burns and DKA, showed a tendency to increase and its severity of illness at hospital presentation. Continual effort and research into the subject should be essential for us to better understand the effects of this new phenomenon of SDMs to protect the well-being of children.

Systematic Review Registration

Clinicaltrials.gov, identifier: CRD42020221215.

Delayed diagnosis and subsequently increased severity of acute appendicitis (compatible with clinical-pathologic grounds) during the COVID-19 pandemic: an observational case-control study

Background

During a global crisis like the current COVID-19 pandemic, delayed admission to hospital in cases of emergent medical illness may lead to serious adverse consequences. We aimed to determine whether such delayed admission affected the severity of an inflammatory process regarding acute appendicitis, and its convalescence.

Methods

In a retrospective observational cohort case-control study, we analyzed the medical data of 60 patients who were emergently and consecutively admitted to our hospital due to acute appendicitis as established by clinical presentation and imaging modalities, during the period of the COVID-19 pandemic (our study group). We matched a statistically control group consisting of 97 patients who were admitted during a previous 12-month period for the same etiology. All underwent laparoscopic appendectomy. The main study parameters included intraoperative findings (validated by histopathology), duration of abdominal pain prior to admission, hospital stay and postoperative convalescence (reflecting the consequences of delay in diagnosis and surgery).

Results

The mean duration of abdominal pain until surgery was significantly longer in the study group. The rate of advanced appendicitis (suppurative and gangrenous appendicitis as well as peri-appendicular abscess) was greater in the study than in the control group (38.3 vs. 21.6%, 23.3 vs. 16.5%, and 5 vs. 1% respectively), as well as mean hospital stay.

Conclusions

A global crisis like the current viral pandemic may significantly affect emergent admissions to hospital (as in case of acute appendicitis), leading to delayed surgical interventions and its consequences.

Impact of the Global COVID-19 Pandemic on the Incidence, Presentation, and Management of Pediatric Appendicitis: Lessons Learned from the First Wave

The fast-evolving nature of the coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented clinical, logistical, and socioeconomical challenges for health-care systems worldwide. While several studies have analyzed the impact on the presentation and management of acute appendicitis (AA) in the adult population, there is a relative paucity of similar research in pediatric patients with AA. To date, there is some evidence that the incidence of simple AA in children may have decreased during the first lockdown period in spring 2020, whereas the number of complicated AA cases remained unchanged or increased slightly. Despite a worrying trend toward delayed presentation, most pediatric patients with AA were treated expediently during this time with comparable outcomes to previous years. Hospitals must consider their individual capacity and medical resources when choosing between operative and non-operative management of children with AA. Testing for severe acute respiratory syndrome coronavirus type 2 is imperative in all pediatric patients presenting with fever and acute abdominal pain with diarrhea or vomiting, to differentiate between multisystem inflammatory syndrome and AA, thus avoiding unnecessary surgery. During the further extension of the COVID-19 crisis, parents should be encouraged to seek medical care with their children early in order that the appropriate treatment for AA can be undertaken in a timely fashion.

Is there an increased incidence of orchiectomy in pediatric patients with acute testicular torsion during COVID-19 pandemic?-A retrospective multicenter study

INTRODUCTION

Testicular torsion is a real emergency condition which requires prompt diagnosis and surgical management to prevent testicular loss. During the coronavirus (COVID-19) pandemic, an increased avoidance of the emergency departments for non-COVID-19 illnesses has been reported in the medical literature.

OBJECTIVE

The aim of this study was to investigate whether the COVID-19 pandemic caused increased number of orchiectomies in pediatric patients presenting with acute testicular torsion compared to pre-COVID-19 period.

STUDY DESIGN

A total number of 119 pediatric patients who underwent surgery for acute testicular torsion from January 2019 to December 2020 were enrolled in retrospective multi-center study from six institutions in Croatia. The patients were divided in two groups. The first group (pre-COVID-19) consisted of the patients who underwent surgery before COVID-19 pandemic (n = 68), while the second group (COVID-19) consisted of the patients who underwent surgery during the COVID-19 pandemic (n = 51). Main outcomes of the study were orchiectomy rates and time from onset of the symptoms to emergency department presentation.

RESULTS

During the COVID-19 pandemic period 43.1% (22/51) of the patients underwent orchiectomy while orchiectomy was performed in 16.2% (11/68) of the patients from the pre-COVID group (p = 0.001). Median time from onset of the symptoms to emergency department presentation during COVID-19 pandemic and pre-COVID-19 periods was 14h (IQR 5, 48) and 6h (IQR 3, 22) (p = 0.007), respectively. A higher proportion of patients waited over 24 h to present to emergency department during the COVID-19 pandemic compared to the pre-COVID-19 period (47% vs 8.8%, p = 0.007).

CONCLUSION

During COVID-19 pandemic a significantly higher rates of orchiectomies and increase in delayed presentations for testicular torsion was found. More patient education during pandemic in regards to management of emergency conditions such as testicular torsion is required.

Concurrent COVID-19 infection in children with acute appendicitis: A report of three cases

Literature describing patients with concomitant COVID-19 infection with acute appendicitis in pediatric patients is growing, and understanding the clinical picture of such patients is relevant in their treatment. We report 3 male children who were surgically treated for acute appendicitis and had concomitant SARS-CoV-2 infection. Our first patient was a 12-year-old male who presented with symptoms indicative of appendicitis but no respiratory symptoms associated with COVID-19 (eg cough, shortness of breath). Laboratory evaluation revealed leukopenia and an elevated C-reactive protein; imaging was consistent with acute appendicitis and an acute pulmonary viral infection. Though he lacked diffuse peritonitis on physical examination or a leukocytosis, he was found to have perforated appendicitis in the operating room. Our second patient was another 12-year-old male whose suspected appendicitis was confirmed via ultrasound and surgery. He tested positive for COVID-19 1 month prior and he continued to test positive for infection on admission without any associated respiratory symptoms. Our third patient was a 13-year-old patient who also presented with symptomatic acute appendicitis without apparent COVID-19 manifestations. These cases provide further examples of pediatric patients with concomitant acute appendicitis and COVID-19 infection, namely an unusual presentation of perforated appendicitis with asymptomatic COVID-19-related pulmonary infection and the more common acute appendicitis with asymptomatic COVID-19 infection.

Impact of the COVID-19 pandemic on incidence and severity of acute appendicitis: a comparison between 2019 and 2020

Background

During the COVID-19 pandemic, a decrease in the number of patients presenting with acute appendicitis was observed. It is unclear whether this caused a shift towards more complicated cases of acute appendicitis. We compared a cohort of patients diagnosed with acute appendicitis during the 2020 COVID-19 pandemic with a 2019 control cohort.

Methods

We retrospectively included consecutive adult patients in 21 hospitals presenting with acute appendicitis in a COVID-19 pandemic cohort (March 15 – April 30, 2020) and a control cohort (March 15 – April 30, 2019). Primary outcome was the proportion of complicated appendicitis. Secondary outcomes included prehospital delay, appendicitis severity, and postoperative complication rates.

Results

The COVID-19 pandemic cohort comprised 607 patients vs. 642 patients in the control cohort. During the COVID-19 pandemic, a higher proportion of complicated appendicitis was seen (46.9% vs. 38.5%; p = 0.003). More patients had symptoms exceeding 24 h (61.1% vs. 56.2%, respectively, p = 0.048). After correction for prehospital delay, presentation during the first wave of the COVID-19 pandemic was still associated with a higher rate of complicated appendicitis. Patients presenting > 24 h after onset of symptoms during the COVID-19 pandemic were older (median 45 vs. 37 years; p = 0.001) and had more postoperative complications (15.3% vs. 6.7%; p = 0.002).

Conclusions

Although the incidence of acute appendicitis was slightly lower during the first wave of the 2020 COVID-19 pandemic, more patients presented with a delay and with complicated appendicitis than in a corresponding period in 2019. Spontaneous resolution of mild appendicitis may have contributed to the increased proportion of patients with complicated appendicitis. Late presenting patients were older and experienced more postoperative complications compared to the control cohort.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00454-y.

Perforated Appendicitis: An Unintended Consequence During the Coronavirus-19 Pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had major clinical impact across the globe. Delayed presentation for medical emergencies has been noted by the medical community. There has been limited reporting on the impact for the care for emergent surgical conditions. We sought to describe the effect of the global pandemic on the presentation and outcomes for the most common urgent general surgery disease process, acute appendicitis.

METHODS

We performed a retrospective review of patients admitted to the United States Naval Hospital Okinawa during the COVID-19 pandemic, from January 2020 to May 2020 (COVID cohort), and compared them to a historical cohort (pre-COVID cohort) over the prior 2 years. Demographics, clinical presentation data, and interventions were collected.

RESULTS

Of the 80 patients with appendicitis, 20% presented perforated. Most patients were male (71%), presented with 1 day of symptoms and had a length of stay of 1 to 2 days. Comparing groups, 13% of the pre-COVID group vs. 31% of the COVID cohort presented perforated (P = .04), with a symptom duration of 1.6 vs. 2.7 days before presentation (P = .075), respectively.

CONCLUSIONS

The COVID-19 pandemic and the global systematic response has impacted unrelated medical and surgical conditions. At our overseas military hospital with minimal disease burden, we observed a delay in presentation for acute appendicitis with a higher incidence of perforation. Patients should be empowered to continue to seek care for urgent and emergent medical and surgical conditions so that they are not harmed by fear of COVID-19 rather than by COVID-19 itself.

Appendicitis during the COVID-19 lockdown: results of a multicenter analysis in Germany

Purpose

The COVID-19 pandemic has transformed medical care worldwide. General surgery has been affected in elective procedures, yet the implications for emergency surgery are unclear. The current study analyzes the effect of the COVID-19 lockdown in spring 2020 on appendicitis treatment in Germany.

Methods

Hospitals that provided emergency surgical care during the COVID-19 lockdown were invited to participate. All patients diagnosed with appendicitis during the lockdown period (10 weeks) and, as a comparison group, patients from the same period in 2019 were analyzed. Clinical and laboratory parameters, intraoperative and pathological findings, and postoperative outcomes were analyzed.

Results

A total of 1915 appendectomies from 41 surgical departments in Germany were included. Compared to 2019 the number of appendectomies decreased by 13.5% (1.027 to 888, p=0.003) during the first 2020 COVID-19 lockdown. The delay between the onset of symptoms and medical consultation was substantially longer in the COVID-19 risk group and for the elderly. The rate of complicated appendicitis increased (58.2 to 64.4%), while the absolute number of complicated appendicitis decreased from 597 to 569, (p=0.012). The rate of negative appendectomies decreased significantly (6.7 to 4.6%; p=0.012). Overall postoperative morbidity and mortality, however, did not change.

Conclusion

The COVID-19 lockdown had significant effects on abdominal emergency surgery in Germany. These seem to result from a stricter selection and a longer waiting time between the onset of symptoms and medical consultation for risk patients. However, the standard of emergency surgical care in Germany was maintained.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02090-3.

The effect of national public health interventions for COVID-19 on emergency general surgery in Northland, New Zealand

Background

The New Zealand government instituted escalating public health interventions to prevent the spread of COVID‐19. There was concern this would affect health seeking behaviour leading to delayed presentation and worse outcomes. The aim of this study was to examine the effects of these interventions on rate and severity of acute general surgical admissions in Northland, New Zealand.

Methods

A retrospective comparative cohort study was performed. Two cohorts were identified: 28 February to 8 June 2020 and same period in 2019. Data for surgical admissions and operations and emergency department (ED) presentation were obtained from the hospital data warehouse. Three index diagnoses were assessed for severity.

Results

There were 650 acute general surgical admissions in 2019 and 627 in 2020 (P 0.353). Operations were performed in 226 and 224 patients respectively (P 0.829). ED presentations decreased from 11 398 to 8743 (P < 0.001). No difference in severity of acute appendicitis (P 0.970), acute diverticulitis (P 0.333) or acute pancreatitis (P 0.803) was detected. Median length‐of‐stay, 30‐day mortality and admission diagnosis were comparable.

Conclusion

Despite a significant reduction in ED presentations, interventions for COVID‐19 did not result in a difference in the rate or severity of acute general surgical admissions.

Where did the patients go? Changes in acute appendicitis presentation and severity of illness during the coronavirus disease 2019 pandemic: A retrospective cohort study

BACKGROUND

The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity.

METHODS

The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019-March 10, 2020 versus March 11, 2020-May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression.

RESULTS

There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47-0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52-1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83-2.25]).

CONCLUSION

The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care-use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.